Provider Demographics
NPI:1255401683
Name:GRAYS HARBOR COUNTY PUBLIC HOSPITAL DISTRICT NO. 1
Entity type:Organization
Organization Name:GRAYS HARBOR COUNTY PUBLIC HOSPITAL DISTRICT NO. 1
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:K
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-346-2222
Mailing Address - Street 1:600 E. MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:ELMA
Mailing Address - State:WA
Mailing Address - Zip Code:98541
Mailing Address - Country:US
Mailing Address - Phone:360-346-2222
Mailing Address - Fax:
Practice Address - Street 1:105 W SIMPSON AVE
Practice Address - Street 2:
Practice Address - City:MCCLEARY
Practice Address - State:WA
Practice Address - Zip Code:98557-9657
Practice Address - Country:US
Practice Address - Phone:360-346-2222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
WAHAC.FS.00000186261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7105406Medicaid
WA106276OtherL&I
WA135OtherREGENCE PRO
WA106275OtherCRIME VICTIM
WA106275OtherCRIME VICTIM
WA135OtherREGENCE PRO